FOUNDATION APPLICATION FORM — CAMYOGA

Email Address *

Phone Number *

Today's Date *

Start Date of Course *

Referral Code

if you have one

Your Postal Address (including postcode) *

Date of Birth *

How long have you been practising yoga? *

How did you hear about this course? *

What motivates you to take this course? *

Do you have any special requirements with reading or writing? Or do you any other special needs? *

Do you have any of the following: *

Please check all that apply

Joint problems

Back or neck problems

Heart problems

Chest pains

Dizziness/Fainting

Recent surgery

Respiratory problems

High or low blood pressure

Depression

Arthritis

Current/recent pregnancy

Carpal tunnel

Ear or eye disorders

Epilepsy

None of the above

If you answered 'yes' to any of the above, please give details below

Do you have any other health conditions? *

Please answer yes or no, and if yes give details

Are you taking any prescribed medication? *

Please answer yes or no, and if yes please give details.

Emergency Contact *

Please provide the following information about your emergency contact. Name, phone number and your relationship to them.

I understand and agree that all deposits and fees are non refundable. *

I understand and agree

foundation yoga application form